The University of Texas Health Science Center at Houston (UTHealth) Cardiovascular Electrophysiology Training Program at McGovern Medical School 2018 Program Application UTHealth / EP Heart Cardiovascular Electrophysiology Training Program Attention: John Boettcher, Program Director 2575 W. Bellfort, Suite 195, Houston, TX 77054 Program website: https://med.uth.edu/epheart/ Email: mary.r.jones@uth.tmc.edu Phone: (713) 486-1645 Application and ALL required material Deadline: March 15, 2018 Application Checklist: Completed and signed program application (MUST BE TYPED) print all pages Passport sized photo A $100.00 non-refundable application fee in the form of money order or cashier s check (no personal checks) payable to UTHealth Cardiovascular Electrophysiology Training Program Only official transcripts will be accepted for application process. Official transcripts for any on-going courses will also be required prior to matriculation, if offered admission (ALL transcripts need to be sent from the educational institution directly to UTHealth Medical School Cardiovascular Electrophysiology Training Program, 6400 Fannin Street-Suite 2550, Houston, TX 77030) Proof of U.S. citizenship or permanent resident status Two letters of reference mailed directly from the individual writing the letter. Reference Letter Request Form must be submitted along with reference letter. Additional Requirements (if admitted into Program) Acceptance is contingent upon successful completion of outstanding prerequisites (if any), immunization screening (see program website), immigration status clearance, Health Care Provider Basic Life Support/CPR certification, Drug Screening, clearance of and mandatory criminal background check.
Office Use Only Checklist Completed: Yes No Date Received: Admission Application UTHealth Cardiovascular Electrophysiology Training Program Submission Deadline: March 15, 2018 Projected Year of Entry 2018 Personal Information Applicant Name: Sex: Male Female Email: Street: Cell Phone: Home Phone: City: State: Country: Zip: Birth Date (mm/dd/yyyy): U.S. Citizen or Permanent Resident Status*: Yes No *International applicants are not being accepted at this time because the program is not currently accredited by the U.S. Department of Education Emergency Contact Information Name: Relation: Address: Phone: City: State: Zip: Email: Education Information (chronological order from the most recent) Dates College/University Location Field of Study Result
Work Experience Information (chronological order from the most recent) May we contact your employers? Yes No Dates Employer Position Supervisor and Title Reason for Leaving Additional Education/Work Experience/Awards/Recognitions/Extra-curricular Activities
Applicant: Prerequisite Form* College/University Cumulative GPA Summary GPA 1. 2. 3. Name Reference Letter List Relationship *Please note that there is a 10-year recency requirement for all prerequisite courses. These courses must have been completed within the last 10 years*
Trainee Statement In the allotted space, write a brief essay describing your background, your interests, your hobbies and your reasons for applying to this program. In your statement, please mention how you learned about this profession and our program. Also, describe why you think you would be an ideal candidate for this program. I certify that the information that I have provided on this application is true and accurate to the best of my knowledge. I understand that willfully withholding information or making false statements may be used as the basis for dismissal or denial of consideration in the program. Signature:
Reference Letter Request Form UTHealth Cardiovascular Electrophysiology Training Program 2575 W. Bellfort, Suite 195, Houston, TX 77054 TRAINEE SECTION: To be completed by the trainee. Present this form and a stamped addressed envelope to an individual that can provide references in the following categories: Academic, Personal character, and Employment. Applicant Name: Applicant Signature: REFEREE SECTION: Please provide the following personal information. Name: Employer: Position: Address: Phone: Signature: Thank you for agreeing to write a reference for the above applicant. This individual has applied for admission to the UTHealth Medical School Cardiovascular Electrophysiology Training Program. Please address the following questions in your reference, attach your reply to this form, and please sign the back of the envelope over the seal and mail it directly to us, in the applicant-provided envelope. Items to include when writing this reference: How do you know the applicant? How long have you known the applicant? Has the applicant discussed his/her motivation for the proposed program of study with you? How well do you know the applicant s academic work? To your knowledge does the applicant have any work experience relevant to this application? To your knowledge does the applicant have any other qualifications relevant to this application? I strongly recommend this applicant for the above program. I recommend this applicant for the above program. I do not recommend this applicant for the above program. Unable to comment